A varicocele is a dilatation of the panpiniform plexus of veins around the testis. A few quick facts:
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Very rarely occur before puberty.
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> 90% only the left testis is affected.
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15% of the normal male population will have a varicocele.
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40% of men with infertility issues have a varicocele.
What causes a varicocele?
There are a number of theories, but with the predominance of varicoceles occurring on the left, anatomical issues are the most likely factor. The Testicular Vein drains directly into the Renal Vein on the left, therefore it is thought that failure of the internal valves in the Left Testicular Vein allows increase in pressure and dilatation of the system. This is very similar to the way varicose veins form in the legs.
Very rarely a large tumour of the left kidney cab block the Renal Vein and cause a varicocele. In this case the varicocele usually appears quite suddenly and is painful.
What are the symptoms?
Most men will have no symptoms at all from the varicocele. They usually notice a swelling in the scrotum, that is often described as a “bag of worms” if large enough.
Some men will find they develop scrotal discomfort after straining or exercise – more commonly at the end of the day when the veins are more likely to be distended. When examining you – the doctor will often get you to perform a Valsalva manouevre to increase the abdominal pressure and therefore inflate the veins.
What tests are required?
The only test that might be required specifically for the varicocele is a scrotal ultrasound – to outline the varicocele and the testes to make sure there are no other problems. Most experienced Radiology services will also screen the left kidney to make sure there is not a (rare) kidney cancer causing the problem.
As varicocele is nearly twice as common in men with fertility issues, many men will also undergo semen analysis (sperm count). Usually this has been performed before the varicocele has been diagnosed but, occasionally, things proceed in reverse order.
What are the treatments?
The majority of men do not require any treatment of their varicocele. There are three situations in which treatment may be offered:
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Infertility – 50% of men with an abnormal semen analysis will demonstrate an improvement after correction of varicocele.
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Discomfort – if a man experiences persistent pain – especially after abdominal straining then correction may be helpful.
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Testicular growth retardation – this is rare but some adolescent males with large varicoceles find that the testis does undergo the normal growth with puberty unless the varicocele is corrected.
Embolisation
This is a therapy that involves the positioning of a coil inside the Testicular Vein, above the level of the dilated Panpiniform Plexus. This takes the pressure off the veins and allows them to shrink. This technique has replaced surgical options for the majority of men who require intervention.
Surgery
This involves identifying the Testicular Vein at some level above the group of veins that are dilated. Once identified, the veins are “tied off” (ligated), following which they slowly shrink over the next few months. This is a day procedure, but the complexity of the surgery varies depending on the individual.